Treating the emergency room as your primary care provider? If you’re a UPMC Health Plan member, you can expect a home visit from the health plan’s community teams of nurses and social workers. Community teams visit these members at home to perform assessments and care management. That’s one of the ways UPMC Health Plan is reducing the rates of avoidable ER use, explains Debra Smyers, senior director of program development at UPMC Health Plan.
UPMC developed community teams to engage members who were having ‘unplanned care’ — members who thought of the emergency room (ER) as their own personal primary care provider (PCP). These teams focus primarily on the Medicaid and special needs populations. UPMC sends health plan nurses and social workers into the community to visit the targeted members in their homes. These visits continue for a few months. Then, the nurse or social worker hands the member over to a different caregiver to continue the care. UPMC calls it a ‘real team approach;’ they even have nurses located in the patient-centered medical home (PCMH) who can link members to an appropriate caregiver. For instance, if the member is a smoker and wants to quit, the nurse would link that member to the lifestyle health coach who helps with smoking cessation.
UPMC Health Plan has also placed a patient navigator in the ER to educate patients on appropriate ER use. These navigators ask patients coming into the ER for a minor illness, such as for a sore throat, if there are any care alternatives they could use instead, such as visiting their PCP. Should the patient not have a PCP, the navigator will then help the patient to find one.
Originally, to identify patients using the ER inappropriately, UPMC would go through a monthly stratification process that included data from previous months. However, this identified patients too long after their ER visit, when it was irrelevant to help the patient. The health plan now uses actual registration data from the ERs to find their targeted patients. With this new plan, UPMC was then able to reach the patient about their ER use on the actual day of the hospital visit. Also, to have a more direct focus on the different patients that were coming into the ER, UPMC stratified all patients into three targeted groups: those with high ER use, those with ER visits for conditions, and those patients with level 1 or 2 ER visits.
UPMC also has a program called Connected Care that helps to improve care coordination for patients with serious mental illnesses. The health plan based this program on the PCMH model of care to address how physical and behavioral healthcare providers can manage the care of this specific population.
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